Application Form

Tel: 020 7259 8100 / Fax: 0207259 8139 E:

W:

PLEASE COMPLETE USING BLACK INK or TYPSCRIPT

POST APPLIED FOR / Honorary Counsellor
APPLICATION REF / (OFFICE USE ONLY)

PERSONAL DETAILS

SURNAME
FORENAME(S) AND TITLE / Mr/Mrs/Miss/Ms/Dr/Other
HOME ADDRESS
POST CODE
HOME TELEPHONE
NO.
MOBILE TELEPHONE NO:
E-MAIL ADDRESS
DATE OF BIRTH / DATE / MONTH / YEAR
NATIONALITY
NATIONAL
INSURANCE NO

EDUCATION/FURTHER EDUCATION (starting with current training)

DATES
FROM / DATES
TO / NAME, ADDRESS AND LOCATION OF SCHOOL, COLLEGE, POLYTECHNIC/UNIVERSITY / COURSE TAKEN, EXAM(S) PASSED / GRADE/
RESULT

TRAINING/CPD:

DETAILS OF ANY RELEVANT TRAINING/CPD UNDERTAKEN:

PROFESSIONAL QUALIFICATIONS OR MEMBERSHIPS

PLEASE GIVE DETAILS INCLUDING DATES OBTAINED. You will be required to produce any relevant certificates or proof of memberships if you are appointed.
Number of clinical hours undertaken to date:
(do not leave blank or your application will not be processed)

EMPLOYMENT HISTORY starting with your last two employments. This should also include any voluntary work.

NAME AND ADDRESS OF
EMPLOYER
POSITION HELD
DATES OF EMPLOYMENT / FROM: / TO:
BRIEF SUMMARY OF DUTIES AND RESPONSIBILITIES
DURATION OF TIME SPENT IN ROLE
REASON FOR LEAVING
NAME AND ADDRESS OF
EMPLOYER
POSITION HELD
DATES OF EMPLOYMENT / FROM: / TO:
BRIEF SUMMARY OF DUTIES AND RESPONSIBILITIES
DURATION OF TIME SPENT IN ROLE
REASON FOR LEAVING

PREVIOUS EMPLOYMENTS including voluntary work.

DATE
FROM / DATE
TO / NAME AND ADDRESS OF EMPLOYER / POSITION HELD AND BRIEF DESCRIPTION OF DUTIES (if clinical work - please give client hours, number of clients seen, 1to1 or group, contract length) / REASON FOR LEAVING

Personal Therapy: Please give details of the personal therapy you have received: include 1to1, family, group and couple

Date Started / Date Ended / No. of sessions / Model used in therapy / Comments if any

Counselling Approach

Please outline your counselling approach

Professional Complaint(s)

Have you had an individual or organisation make a complaint against you while working as a counsellor/psychotherapist etc? No / Yes (Please give details)

Please state your reasons for applying for a volunteer trainee counselling placement. Please also state what skills, interests and experience you would bring to the position and provide details of any other relevant information, including voluntary work experience.

Please put a tick in the day and time slot in the table below when you would be available for counselling sessions.

Day / Morning:
9.00-13.00 / Afternoon:
14.00-17.00 / Evening:
18.00-21.00
Monday
Tuesday
Wednesday / *
Thursday
Friday

*You will need to attend fortnightly supervision on a Wednesday evening as part of your placement with us.

REHABILITATION OF OFFENDERS - having a criminal record will not necessarily be a bar to obtaining a position or placement and Westminster Mind will not unfairly discriminate against the subject of Disclosure of information on the basis of conviction or other details revealed.

Have you ever been convicted of a criminal offence (declaration subject to the Rehabilitation of Offenders Act 1974)? / YES □ NO □

If you have been convicted of a criminal offence, please give details of the offence(s) that are not spent, including date(s) and sentence(s)

DATE / OFFENCE / SENTENCE

PROTECTION OF VULNERABLE ADULTS SCHEME - CARE STANDARDS ACT

Have you ever knowingly been the subject of any investigation or enquiry into an allegation of possible abuse of a child or vulnerable adult? / YES □ NO □

If yes please give full details and dates

DISABILITY

Wandsworth & Westminster Mind welcomes applications from all sectors of the community, including applicants with a disability. The Disability Discrimination Act 1995 defines disability as ‘a physical or mental impairment which has a substantial and long term adverse effect on the ability to carry out day to day activities’.

Do you consider that you have a condition (medical or otherwise) which would be likely to have an effect on your ability to undertake volunteering?

YES □ NO □

If you have a disability, please state whether you would need any arrangements to be made if you were invited to attend for interview.

Please state below details of any adjustment which would need to be made in order for you to take up a volunteer counselling placement, if appointed.

ANY OTHER ADDITIONAL INFORMATION Please include any language skills that you have.

REFERENCES: Please give the names and addresses of two referees we can contact, one of whom should be your tutor, or supervisor of your clinical work. We will not normally take up references until after the interview.

NAME
FULL ADDRESS
POST CODE
E-MAIL (if known)
RELATIONSHIP
(employer, manager, friend) / HOW LONG HAS THIS PERSON KNOWN YOU
NAME
FULL ADDRESS
POST CODE
E-MAIL (if known)
RELATIONSHIP
(employer, manager, friend) / HOW LONG HAS THIS PERSON KNOWN YOU?

DECLARATION

I declare that the information that I have given in this application is correct to my best belief and knowledge. I understand that my application may be rejected or any offer of a volunteer counselling placement withdrawn if I have given false information or withheld relevant details. I also understand that if it is found, subsequent to my appointment, that inaccurate details have been provided or relevant details withheld, this is liable to result in the termination of my counselling placement without notice. I consent to the Charity processing my personal data, as well as my personal sensitive data, given in this application (and on the Equal Opportunities Monitoring form) for the following purposes: administrative purposes and for complying with any laws, regulations and procedures.

Signature
Date